A Trump Administration will work with Congress to repeal the ACA and replace it with a solution that includes Health Savings Accounts (HSAs), and returns the historic role in regulating health insurance to the States. The Administration’s goal will be to create a patient-centered healthcare system that promotes choice, quality and affordability with health insurance and healthcare, and take any needed action to alleviate the burdens imposed on American families and businesses by the law.

Not surprisingly, health care, and more specifically the fate of the ACA, is squarely on the table. Repealing the ACA has been a repeated strategy among Republicans in Congress. Now, with interests more clearly aligned among the newly elected members of the executive and legislative branches, many health policy wonks are weighing in on what can actually happen. Despite many thoughtful opinions on the topic, major uncertainty remains.

With that said, there is pretty much agreement on the means by which the ACA could be dismantled. In order to do a full repeal, Republicans would need 60 votes in the Senate to prevent a filibuster by Democrats. Unless there is a Republican strategy for eliminating the opportunity to filibuster, as Austin Frakt has suggested or the ability of the Democrats to maintain a filibuster wains throughout the Trump presidency as Megan McArdle from BloombergView posits, a full repeal is likely off the table.

Filibuster issue aside, remember how Obamacare was passed by Democrats once Republican Scott Brown won the Massachusetts Senate seat? Yes, that’s right – budget reconciliation. This process cannot be stopped by a filibuster, so a simple majority is sufficient. There are some limitations on what can be included in a budget reconciliation process. Tim Jost’s recent blog post on Health Affairs explains this well:

Budget reconciliation legislation is subject to strict procedural and substantive limits. Reconciliation in the Senate can only contain provisions that affect the revenues and outlays of the United States and cannot contain “extraneous provisions” that only incidentally affect revenue and expenditures. Budget reconciliation is a two-step process—first Congress adopts a budget resolution with instructions to committees to meet reconciliation targets and then it adopts the reconciliation itself. This cannot happen on “day one.”

This strategy was attempted earlier this year when the Restoring Americans’ Healthcare Freedom Reconciliation Act was sent to President Obama’s desk. President Obama vetoed it, but we cannot expect the same response from President Trump.

In addition to reiterating the likelihood of the process, the budget reconciliation bill sent to President Obama earlier this year gives us some insight into which components of the ACA might be on the chopping block. The Congressional Budget Office (CBO) scored the bill, and a House summary highlights many of the ACA provisions at risk, detailing the elimination of: the optional Medicaid expansion, tax credits (i.e., subsidies) for health insurance premiums in the exchanges, the individual mandate and penalties, employer requirements and associated penalties, the Prevention and Public Health fund, and the higher Medicare tax rate for individuals above $200,000 and couples making more than $250,000, among other things. Importantly, this bill reinstated additional payments for providers with a disproportionate share of Medicaid and uninsured recipients, since those providers would no longer being receiving reimbursement through insurance for this population and included some funding for state substance use and mental health programs.

Regardless of the means of repealing provisions of the ACA, there remains uncertainty about what a replacement plan would look like. We don’t know when the replacement will come. Will replacement be ready to go alongside the dismantling of other aspects of the ACA? Or will the ACA be taken down first? And perhaps even more importantly, what will a replacement include? As detailed in President Elect Trump’s recently released proposal, health savings accounts and enabling individuals to buy insurance across state lines appear to be central to his plan for replacement. We could also look to Speaker of the House Paul Ryan’s proposal for replacement, which has slightly more details. Here, we see some support for keeping private insurance reforms that are part of the ACA (e.g., keeping young adults on their parents’ plan until age 26 and protection for people with pre-existing conditions). This is consistent with President Elect Trump’s recent change in rhetoric, although not in substance, from his interview with the Wall Street Journal on Friday after the election where he suggested he was open to keeping these two components of the ACA in place. Perhaps he now knows that a full repeal is not possible.

There is also debate about what will happen to the Innovation Center at CMS, the hub of payment and delivery system reform innovation created through the ACA. While the recent bipartisan MACRA law has embedded value-based payment into the Medicare program outside of the ACA, there has been reported opposition to the Innovation center by Republicans in the past.

On the other hand, there is a real question of whether the Trump Administration and the Republicans in Congress will actually go through with the dismantling as proposed. For example, McArdle suggests Republicans might not really want to eliminate some of the ACA provisions. She rightly explains that there are parts of the ACA that are particularly popular with Americans, especially the private health insurance reforms that make it possible for people who are sick to get health insurance without having to pay more.

One thing is certain. The Republicans now dictate the health care reform agenda and there are serious concerns about what a dismantling of the ACA would mean for many Americans struggling to pay their health care bills and access to high quality health care, not to mention the potential impact on the federal deficit. Despite the rhetoric that suggests the Trump Administration will eliminate the ACA right away, the reality of the policy making process, implementation challenges, and the desire not to throw people off of health insurance overnight suggest that most of the significant changes to the ACA will take some time.

Dr. Daniel Carr, Director of the Pain Research, Education and Policy Program at Tufts University School of Medicine recently moderated an esteemed panel at the International Conference on Opioids held at Harvard University. Panelists included all six governors of the New England states: Gov. Charlie Baker, MA; Gov. Maggie Hassan, NH; Gov. Paul LePage, ME, Gov. Dannel Malloy, CT; Gov. Gina Raimondo, RI; and Gov. Peter Shumlin, VT. The discussion of state by state initatives was framed around the topic of the conference: Opioids the New Normal — The future of opioid prescription. The balance between opioid overuse and addiction and effective treatment for those suffering with chronic pain is a difficult one. The bipartisan panel agreed that a multimodal approach will be necessary for systemic societal change. To watch the entire panel discussion moderated by Dr. Carr, click here This unprecedented forum was featured in a wide variety of media, including a front cover editorial (“Self-medicating in the opioid crisis”) in the June 18 issue of The Lancet.

The American Academy of Pain Medicine recently held a scientific meeting with several PREP-affiliated presenters. The topic “Non-pharmacological/Integrative Therapies: Pearls” was moderated by former PREP student, Heather Tick, MD, of the University Washington, Seattle.

The panel featured current PREP student, Marta Illueca, MD, sharing insights on spirituality and religion-based therapies across the continuum of pain and suffering; as well as PREP guest lecturer, Beth Murinson Hogans, MD discussing evidence-based recommendations for acupressure versus trigger-point massage.

The Pain Research, Education and Policy Program (PREP) is exceptionally proud that program’s director and co-founder, Dan Carr, MD is currently serving as the president of the American Academy of Pain Medicine, furthering the mission of the PREP program: “To champion an interprofessional educational program that addresses the multidimensional public health burden of pain by preparing diverse learners to contribute with expertise and compassion to pain research, education and policy.”

The U.S. Department of Health and Human Services has announced the federal government’s first coordinated plan for addressing the immense burden of pain that affects millions of adults and children in the United States. The National Pain Strategy (NPS) is a direct result of recommendations put forth in the 2011 Institute of Medicine’s report, Blueprint for Transforming Pain, Prevention, Care, Education and Research, calling for a cultural transformation in pain prevention, care and education as well as recommending a comprehensive population health-level strategy.

Dr. Daniel Carr

Patients, patient advocates, researchers, and pain-related professional groups such as the American Academy of Pain Medicine (AAPM) played an instrumental role in the development of the National Pain Strategy (NPS). Participants included Dr. Daniel Carr, the director of the Pain Research, Education and Policy Program (PREP) at Tufts University School of Medicine and the current president of the American Academy of Pain Medicine. In discussing the importance of the National Pain Strategy and its relevance to the public health crisis surrounding opioid abuse, Dr. Carr stated “The NPS is comprehensive and far-reaching in scope. The other influential pain report released within days of the NPS — CDC’s Guideline on Opioid Prescribing — extends current efforts focused upon reducing opioid abuse. I believe the opioid epidemic will be brought under control, in large part through public and professional education about the broad spectrum of options for treating pain, as advocated in the NPS. As the opioid epidemic recedes, patients, health care professionals, and policy makers will look to the NPS for guidance on enduring, systems-level solutions to improving the assessment, treatment and prevention of pain–and reducing disparities in access to quality pain care.”

The Pain Research, Education and Policy program at Tufts will continue to lead the way in training leaders in the comprehensive field of pain, working to reduce the burden of pain and suffering for individuals, families and society.

The PREP program congratulates faculty member Carol Curtiss, MSN, RN-BC on the publication of her article, I’m Worried About People in Pain, in the American Journal of Nursing ( AJN, Jan 2016, Vol 116, No. 1). Carol skillfully argues that while both chronic pain and prescription drug abuse are public health crises in the U.S., efforts to address opioid abuse may lead to unintended consequences for people who suffer with persistent pain and benefit from responsible use of opioids as part of a comprehensive treatment plan. As we tackle the complex public health crisis of prescription abuse through regulation and policy, we must also remain cognizant of the needs of those who suffer from chronic pain by including pain clinicians and patients at the health policy table.

We were delighted and extremely proud to learn that PREP graduate and faculty member Pamela Ressler, MS, RN, HNB-BC was just named to the Medicine X Program Executive Board as a Senior Leader for this renowned, cutting edge program. Six years ago while a student in the PREP program, Pam began to explore the use of social media by patients with chronic pain and other disabilities, as a mean to overcome their social isolation. Pam started and maintains this same PREP-Aired blog. Pam’s award-winning PREP Capstone project characterized this emerging social trend in detail, and led to subsequent publications in the professional and lay press, and numerous speaking engagements. She has collaborated with other faculty members in Public Health at Tufts, including Libby Bradshaw, Lisa Gualtieri and Ken Chui, in the PREP and Health Communication programs.

As a faculty member in the PREP program, Pam has taken on the role of Course Director for established courses such as those on the social and ethical dimensions of pain, and end-of-life and palliative care issues (another section of the latter course is taught by Lewis Hays). Recently with the assistance of PREP faculty Maureen Strafford, Pam inaugurated a well-received PREP course in mindfulness and pain. Outside of the PREP program, Pam is the founder of Stress Resources in Concord, Massachusetts, a firm specializing in building resiliency for individuals and organizations through tools of connection, communication and compassion.

Pam first began to present at Medicine X in 2014. As described on its website, Medicine X is an initiative “designed to explore the potential of social media and information technology to advance the practice of medicine, improve health, and empower patients to be active participants in their own care. The ‘X’ is meant to evoke a move beyond numbers and trends—it represents the infinite possibilities for current and future information technologies to improve health. Under the direction of Dr. Larry Chu, Associate Professor of Anesthesia, Medicine X is a project of the Stanford AIM Lab.”

]]>http://sites.tufts.edu/prep/2016/01/26/pamela-ressler-medicine-x/feed/0Pain into Process: A PREP Graduate’s Before and After Look at Taking Her Own Medicinehttp://sites.tufts.edu/prep/2015/10/25/pain-into-process/
http://sites.tufts.edu/prep/2015/10/25/pain-into-process/#respondSun, 25 Oct 2015 20:17:10 +0000https://sites.tufts.edu/prep/?p=781Guest blogger: Felice Indindoli, MS-PREP 2015, MAc 2015, Tufts University School of Medicine, Pain Research, Education and Policy Program

Raring to go! That’s me. Upon entering the MS-PREP program I made quick work of getting a grant and press pass to fly out to the PainWeek Conference, 2013, in Las Vegas. It comes with my territory; jump with both feet or don’t jump (it hurts more when you leave a limb behind) and it was time to immerse myself in the goings-on in the world of pain research.

My prior ventures into pain research and theories about pain were mainly on the literary side. Great writers have said great things about the human experience of pain with full realization that cosmic irony applies; language fails us in the face of pain. From the point of view of narrative, this is a massive conundrum. A lot can be said about that, or nothing.

Off I went to PainWeek with an editor’s sense of story development. I was eager to report on the conference. And, as someone not new to the learning process, I wanted to discover just what I’d gotten myself into pursuing both research and clinical degrees in pain management.

Kid in a candy store. That was me at the conference. But, in wrangling with the mountain of new material I had to absorb, fascinating though it was, I found myself in an odd place: speechless. Looking back, it was an apt response (or lack thereof and still appropriate) in the face of so much new information. Odd how it seemed to parallel what I knew from literature about the language of pain, the metaphors and analogies all refer to the evaporation of meaning in language. Words mean nothing. Or, given a state of pain, one has no words at all.

I left the conference with my memory and laptop stuffed with information about pain research. The second year of my acupuncture program was already in session and I’d just missed a cool week of class and lab to attend the conference. As I started to unpack what I’d learned, the writing process turned swiftly from thinking about what I had learned to, “what was I thinking?” in taking on a full week of pain research. Ouch…no pun intended.

Some of the most thought provoking talks at the conference were subjects I would soon tackle in PREP classes, under the tutelage of highly experienced teachers and mentors, which proved essential to my gradual understanding of the landslide of pain information I had subjected myself to…willingly, I might add. The following topics were of particular interest:
• Learning to Unlearn: How Coaching is Changing the Pain Management Landscape
• When Does Acute Pain Become Chronic?
• The Complexity Model: A Novel Approach towards Improving the Treatment of Chronic Pain
• Glia and Chronic Pain
• Teaching the Five Pain Coping Skills
• The Mad Woman in the Attic: Pain and Personality Disorders
• Chronic Pain in Children: Are they a Population at Risk?
• Drug Diversion VS Pain Management: Finding a Balance
• Opioid-Induced Hyperalgesia: Clinical Implications for Pain Practitioners
• Rational Polypharmacy
• Interview with an anesthesiologist and researcher working on a new drug NKTR-181 (now in phase 3 trials): taking the likeability out of pain medication via slow rate of entry
• Living on the Edge: Depression, Pain, and Suicide

The above lists only a handful of the talks I attended during the week-long conference. But, hopping from bullet to bullet, this list traces my learning curve in the PREP program. Pain topics in 2013 have not fallen off the table in 2015; they remain relevant.

What did I know before I started the PREP program? As I mentioned, reading about the human experience of pain from the literary side only goes so far in the understanding of that experience from the clinical side, the pragmatics of what it means to diagnose, treat, and manage pain. What I did not know before the PREP program is that each time one approaches a patient with a pain dilemma, one immediately steps into a minefield of several other issues. The ripple effect was new to me. Pain isn’t separate from anything—it’s a cause and an effect. I began to understand this concept during the PainWeek conference and it was hugely motivating. I was also starting to see patients as an assistant and then intern in my acupuncture training—the “ah-ha!” light bulbs were going off everywhere. Almost too many to manage. For a newbie, the deep-dive into pain research, education and policy brought me to a place of near blindness. Education shines a very bright light on the unknown…you do the math.

The 12 bullets listed above weren’t just talks I attended at the conference; they represent opening lectures in my education on pain. Concepts in ethics and culture that I knew from literary references were turned, virtually overnight, into case studies on the impact society and our ability to listen to medical narrative have on the pain patient. Haruki Murakami, in his book 1Q84, says, “I can bear any pain as long as it has meaning.” For a healthcare practitioner, this is the hallmark of bearing witness: enter Social and Ethical Aspects of Pain, PREP 232, with Pam Ressler and Dr. Libby Bradshaw. This was the class in which I discovered my capstone topic (though I didn’t know it at the time). I remember admitting to Pam that my topic was messy, disorganized, big holes in the research, more questions than answers and that perhaps I shouldn’t “go there.” Her answer was, “perhaps you should.”

Topics on pharmacy and medicine that had been the subject of my pre-med studies, an interest in the history of medicine, and web content on parenting, were addressed in detail in Neuroanatomy and Neurochemistry of Pain, PREP 230, and Introduction to Clinical Pain Problems, PREP 234, with Dr. Dan Carr, Ewan McNichol, and Dr. Steve Scrivani. We examine the physical, the empirical while understanding that the experience and expression of pain do not survive our granular look at the specifics; in fact, they seem to evaporate. More neurons, less person. More person, less neurons. Either way, we may try to get our hands on the shadow of pain left by a scar and chase it into a corner so we might label it, manage it, or at the very least identify it with nothing to use as a benchmark or basis of comparison. We understand that Palahniuk’s words in his nightmarish Diary, “We have no scar to show for happiness,” underscore the horror inherent in grappling with pain; happiness will not be found hiding under the scar or by following the pain once its neurological pathway is established–it’s somewhere else. Where, you ask? Cue the psyche.

On matters existential and psychiatric, I would point to Shakespeare for a juicy literary explanation that undoubtedly summed up a world of hurt in verse. This resonates with other literary critics, such as Elaine Scarry in her book, The Body in Pain. She suggests, “Whatever pain achieves, it achieves in part through its unsharability, and it ensures this unsharability through its resistance to language. [She continues] “English,” writes Virginia Woolf, “which can express the thoughts of Hamlet and the tragedy of Lear has no words for the shiver or the headache.” … Physical pain does not simply resist language but actively destroys it.” For all her insight into Virginia Woolf and the human body as a political map, Scarry didn’t make patients more real to me than evaluating them in Dr. Kulich’s class, Psychological Approaches to Pain Management, PREP 238. That mangled language left in the wake of pain can be even more difficult to interpret in those patients who struggle with disorder, in and of itself, applied not only to their expression of pain but also to their thought processes and mental health. I remember the talk given at PainWeek, The Madwoman in the Attic: Pain and Personality Disorders, which borrowed its title from the landmark text written by Gilbert and Gubar, with the intention of infusing a ruthlessly unfunny topic with some sense of humor.

Of drug diversion, complexity models, and clinical trials, I can’t say I have a good literary reference. I was enlightened, however (and not without some degree of pain) by two epidemiology and biostatistics classes, Professor Mark Woodin’s Principles of Epidemiology, PH 201, and Professor Janet Forrester’s Epi-Bio: Reading Medical Literature, HCOMM 502. I can return to the PainWeek slide presentation on NKTR-181 and make sense of the visual display of the quantitative analysis. This feels like a different type of accomplishment to me, like looking under the hood of a car and knowing what to do. At the same time, one needs to be able to reverse-engineer the information; take the information, understand it scientifically, express it and then turn it back into information accessible to a lay audience, perhaps a patient. Alia Bucciarelli was instrumental in helping me further hone my writing and editorial skills by using them to address scientific and medical information in a semester-long directed study in Advanced Writing for Medicine, PREP 400. We took the research from my capstone project and turned it around for parents of adolescent girls with chronic abdominal pain. It’s not a short journey from a systematic search in PubMed, to articles on pediatric abdominal pain, to interpreting the stats and overarching epidemiological issues, to analysis and back again but writing this time 5 truly cogent bullet points for parents in need of reliable information.

For the PainWeek talks that focused on educational issues and touched on healthcare policy, I was able to lean into some literary insights on pain. The discussions about children and chronic pain research as well as the pitfalls of trying to teach adult chronic pain patients coping skills, I would later learn in Dr. Srdjan’s Nedeljkovic’s class on Public Policy, Legislative, and Forensic Issues in Pain, PREP 235, were both examples of those minefields I mentioned earlier. Children and pain research, adults and coping skills to manage reliance on medication—instant ethics dilemmas served up with a side of forensics. For literary references, there are two that I like. One is from C.S. Lewis in his book, The Problem of Pain. He says, “Pain insists upon being attended to. God whispers to us in our pleasures, speaks in our consciences, but shouts in our pains. It is his megaphone to rouse a deaf world.” What can we do, what are we supposed to do when roused in this way for the sake of children who are sick and in pain? More concerning is what happens when we do nothing. Of all of the PREP classes I took, it was in this class that I found myself dumbfounded more often than not in the face of policies that both help and hurt, the clever maneuvering of legal language that sometimes, always, or never (you chose) lives up to the actions it purports to protect or expose. But, one must understand these things in order to navigate the minefield of pain issues in a given case—it’s never just one patient, with one problem, somehow in a vacuum. For discussions about pain and education in general, I will end with my favorite literary author on pain, Alphonse Daudet. His book, In the Land of Pain, written in the late 19th Century while suffering the final stages of tertiary syphilis, is a simple yet brilliant collection of the writer’s thoughts and feelings. It brings us back to the significance of language in the study of pain. Daudet asks, “Are words actually any use to describe what pain really feels like? Words only come when everything is over, then things have calmed down. They refer only to memory, and are either powerless or untruthful.”

This is the essence of what I learned both at the PainWeek Conference and in the PREP program: the value of listening. It’s the golden rule of pain management. Learn how to do it and why. Policy or poetry? You tell me. Actually, I’ll let my patients do the talking.

When Pope Francis recently visited the United States, CNN asked its viewers to share, in three words, what the Pope meant to them. What a brilliant idea! As September is Pain Awareness Month, we in the PREP program put forth a similar challenge to our alumni, faculty and current students. We asked “what three words express what you want the world to know about pain”. Here are the results of our query in the form of a word cloud and some three word phrases:

“Don’t give up”

“Try acupuncture first”

“The invisible captivity”

“Share with us”

“Don’t be afraid”

“There is hope”

What three words express what you want the world to know about pain? We welcome your comments.

Five graduating PREP students took to the lectern on August 10, presenting their capstone projects to an audience of faculty, students, alumni, family and friends. After rigorous study and investigation, each student highlighted their chosen area of interest. While the capstones mark the culmination of matriculation in the PREP program, each of the graduates plan on continuing to expand their capstone projects in the areas of education, policy, and research as they move into their careers.

]]>http://sites.tufts.edu/prep/2015/08/11/august-capstone-presentations/feed/0Spring 2015 Capstones Reflect the Multidisciplinary Focus of the PREP Programhttp://sites.tufts.edu/prep/2015/05/19/spring-2015-capstones-reflect-the-multidisciplinary-focus-of-the-prep-program/
http://sites.tufts.edu/prep/2015/05/19/spring-2015-capstones-reflect-the-multidisciplinary-focus-of-the-prep-program/#respondTue, 19 May 2015 19:40:28 +0000https://sites.tufts.edu/prep/?p=759The Pain Research, Education and Policy program prides itself in addressing the complex nature of pain in the individual and in society through multidisciplinary learning and collaboration. The 2015 capstone projects exemplified the depth and breadth of the program by the varied nature of the graduating students’ innovative selection of topics and research. Congratulations to these members of the MS-PREP Class of 2015, the next generation of leaders in the field of pain.